Development of the A-DIVA Scale

Abstract

Placement of a peripheral intravenous catheter is a routine procedure in clinical practice, but failure of intravenous cannulation regularly occurs. An accurate and reliable predictive scale for difficult venous access creates the possibility to use other techniques in an earlier time frame.We aimed to develop a predictive scale to identify adult patients with a difficult intravenous access prospectively: the A-DIVA scale.This prospective, observational, cross-sectional cohort study was conducted between January 2014 and January 2015, and performed at the department of anesthesiology of the Catharina Hospital (Eindhoven, The Netherlands). Patients 18 years or older were eligible if scheduled for any surgical procedure, regardless ASA classification, demographics, and medical history.Experienced and certified anesthesiologists and nurse anesthetists routinely obtained peripheral intravenous access. Cannulation was performed regarding standards for care.A failed peripheral intravenous cannulation on the first attempt was the outcome of interest.A population-based sample of 1063 patients was included. Failure of intravenous cannulation was observed in 182/1063 patients (17%). Five variables were associated with a failed first attempt of peripheral intravenous cannulation: palpability of the target vein (OR = 4.94, 95% CI [2.85–8.56]; P < 0.001), visibility of the target vein (OR = 3.63, 95% CI [2.09–6.32]; P < 0.001), a history of difficult peripheral intravenous cannulation (OR = 3.86, 95% CI [2.39–6.25]; P < 0.001), an unplanned indication for surgery (OR = 4.86, 95% CI [2.92–8.07]; P < 0.001), and the vein diameter of at most 2 millimeters (OR = 3.37, 95% CI [2.12–5.36]; P < 0.001). The scoring system was applied in 3 risk groups: 36/788 patients (5%) suffered from a failed first attempt in the low-risk group (A-DIVA score 0 or 1), whereas the medium (A-DIVA score 2 or 3) and high-risk group (A-DIVA score 4 plus), included 72/195 (37%) and 74/80 (93%) patients with a failed first attempt of inserting a peripheral intravenous catheter, respectively.The additive 5-variable A-DIVA scale is a reliable predictive rule that implies the probability to identify patients with a difficult intravenous access prospectively.Dutch Trial Register (ref: 4595).

Defining risk factors associated with difficult peripheral venous Cannulation: A systematic review and meta-analysis

“…Variables related to vascular access conditions were included in all the studies, though heterogeneously assessed, which prevented the development of meta-analysis. In this group, a previous history of multiple punctures 38,40,42 or a previous use of 'rescue techniques' 42,43 resulted to be significant risk factors in some studies. In addition, the ability to locate a target vein by visualization (vein visibility) or palpation (vein palpability) after tourniquet is associated to technique success and the appearance of DPIVC.…”

The Modified A-DIVA Scale as a Predictive Tool for Prospective Identification of Adult Patients at Risk of a Difficult Intravenous Access: A Multicenter Validation Study

“…Intravenous therapy can be defined as any form of treatment in which access to a vein is necessary [1,6,8]. The procedure of peripheral intravenous cannulation is performed routinely in daily clinical practice, while the first attempt to obtain an intravenous access is not successful in every patient [2,4,5,8,9,10,11]. A recently published systematic review and meta-analyses reported a failure rate of up to 30% on the first attempt of peripheral intravenous cannulation with the conventional approach [6].…”

“…This conventional approach of peripheral intravenous cannulation involves visual inspection and palpation of the extremity to locate a vein, followed by a needle puncture and catheter insertion [8,12]. Notwithstanding, intravenous access can be difficult to obtain, especially in patients with a lack of visual or palpable apparent veins, smaller veins, and in patients with a known history of a difficult intravenous access [11].…”

“…In routine clinical practice, a difficult intravenous access is identified after performing multiple attempts to insert an intravenous catheter. Identification of the presence of a difficult intravenous access prospectively, however, can possibly lower the incidence of a failed first attempt of inserting a peripheral intravenous catheter and improve patients’ outcomes [6,11]. The A-DIVA scale (Adult Difficult IntraVenous Access Scale) is a recently created predictive scale to identify patients with a difficult intravenous access [11].…”

“…Identification of the presence of a difficult intravenous access prospectively, however, can possibly lower the incidence of a failed first attempt of inserting a peripheral intravenous catheter and improve patients’ outcomes [6,11]. The A-DIVA scale (Adult Difficult IntraVenous Access Scale) is a recently created predictive scale to identify patients with a difficult intravenous access [11]. This additive A-DIVA scale implies the prediction of the likelihood of a difficult intravenous access in adult patients prospectively based on clinical observations, and consisted of five variables, including an inability to detect a vein suitable for cannulation by palpating and/or visualizing the extremity, a vein diameter of two millimeters or less, a known history of a difficult intravenous access, and an emergency indication for surgery [11].…”